eScholarship Title The six most essential questions in psychiatric diagnosis: a pluralogue part 3: issues of utility and alternative approaches in psychiatric diagnosis Permalink https://escholarship.org/uc/item/25d7x561 Journal Philosophy, Ethics, and Humanities in Medicine, 7(1) ISSN 1747-5341 Authors Phillips, James Frances, Allen Cerullo, Michael A et al. Publication Date 2012-05-23 DOI http://dx.doi.org/10.1186/1747-5341-7-9 Peer reviewed eScholarship.org Powered by the California Digital Library University of California Phillips et al. Philosophy, Ethics, and Humanities in Medicine 2012, 7:9 http://www.peh-med.com/content/7/1/9 REVIEW Open Access The six most essential questions in psychiatric diagnosis: a pluralogue part 3: issues of utility and alternative approaches in psychiatric diagnosis James Phillips1*, Allen Frances2, Michael A Cerullo3, John Chardavoyne1, Hannah S Decker4, Michael B First5, Nassir Ghaemi6, Gary Greenberg7, Andrew C Hinderliter8, Warren A Kinghorn2,9, Steven G LoBello10, Elliott B Martin1, Aaron L Mishara11, Joel Paris12, Joseph M Pierre13,14, Ronald W Pies6,15, Harold A Pincus5,16,17,18, Douglas Porter19, Claire Pouncey20, Michael A Schwartz21, Thomas Szasz15, Jerome C Wakefield22,23, G Scott Waterman24, Owen Whooley25 and Peter Zachar10 Abstract In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM – whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. General introduction the DSM-5 work in which he focused both on issues of For the full text of the General Introduction to the entire transparency and issues of process and content [2-15]. article, the reader is referred to Part 1 [1]. The General In the course of this debate over DSM-5 I proposed to Introduction reviewed the history of the article, which Allen in early 2010 that we use the pages of the Bulletin originated in a controversy initiated by Robert Spitzer of the Association for the Advancement of Philosophy and Allen Frances, Chairmen respectively of the DSM- and Psychiatry (of which I am Editor) to expand and III and DSM-IV Task Forces, over the ongoing work of bring more voices into the discussion. This led to two the DSM-5 Task Force and Work Groups. In a series of issues of the Bulletin in 2010 devoted to conceptual issues articles and blog postings in Psychiatric Times, Frances in DSM-5 [16,17]. (Vol 17, No 1 of the AAPP Bulletin will (at times with Spitzer) carried out a sustained critique of be referred to as Bulletin 1, and Vol 17, No 2 will be re- ferred to as Bulletin 2. Both are available at http://alien. * Correspondence: [email protected] dowling.edu/~cperring/aapp/bulletin.htm.) Interest in this 1 Department of Psychiatry, Yale School of Medicine, 300 George St, Suite topic is reflected in the fact that the second Bulletin issue, 901, New Haven, CT 06511, USA Full list of author information is available at the end of the article with commentaries on Frances’ extended response in the © 2012 Phillips and Frances; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Phillips et al. Philosophy, Ethics, and Humanities in Medicine 2012, 7:9 Page 2 of 15 http://www.peh-med.com/content/7/1/9 first issue, and his responses to the commentaries, reached by an extensive empirical foundation. Our highest priority over 70,000 words. has been to provide a helpful guide to clinical practice. Also in 2010, as Frances continued his critique We hoped to make DSM-IV practical and useful for clini- through blog postings in Psychiatric Times, John Sadler cians by striving for brevity of criteria sets, clarity of lan- and I began a series of regular, DSM-5 conceptual issues guage, and explicit statements of the constructs embodied blogs in the same journal [18-31]. in the diagnostic criteria. An additional goal was to facili- With the success of the Bulletin symposium, we tate research and improve communication among clini- approached the editor of PEHM, James Giordano, about cians and researchers” ([33], p. xv). using the pages of PEHM to continue the DSM-5 discus- The primary achievement of DSM-III and DSM-IV was sion under a different format, and with the goal of reach- the establishment of reliability through the use of diagnos- ing a broader audience. The new format would be a series tic criteria. The criteria worked to assure consistency of of “essential questions” for DSM-5, commentaries by a diagnosis across settings. Psychiatrists using the same diag- series of individuals (some of them commentators from nosis had the comfort of knowing that they were talking the Bulletin issues, others making a first appearance in this about the same patients - or that two psychiatrists evaluat- article), and responses to the commentaries by Frances. ing the same patient would make the same diagnosis. As Such is the origin of this article. (The general introduction, sensible as this rationale is, it leaves questions open - who individual introductions, and conclusion are written by in fact actually uses the diagnostic criteria, and for whom this author (JP), the responses by Allen Frances. are they really important? For this exercise we have distilled the wide-ranging In discussing these questions, we should not forget that discussions from the Bulletin issues into six questions: the DSM manuals also provide thorough descriptions of 1) the nature of a mental disorder; 2) the definition of the respective disorders, what we may call descriptive, mental disorder; 3) the issue of whether, in the current phenomenological, or prototypal accounts. Among the state of psychiatric science, DSM-5 should assume a various user groups - clinicians, students, and researchers, cautious, conservative posture or an assertive, trans- to name the three cited in the above quotation from the formative posture; 4) the role of pragmatic considera- DSM-IV Introduction - who uses what? The available re- tions in the construction of DSM-5; 5) the issue of search [34] supports one’s anecdotal impression that utility of the DSM – whether DSM-III and IV have been experienced clinicians use the descriptive prototypes, call- designed more for clinicians or researchers, and how this ing on the criteria for the occasional infrequently used conflict should be dealt with in the new manual; and 6) diagnosis, and that students and researchers are the main the possibility and advisability, given all the problems users of the criteria. This is hardly surprising. Clinicians with DSM-III and IV, of designing a different diagnostic are focused on treating their patients, not checking cri- system. Part 1 [1] of this article covered the first two teria, and are usually working with a mental grasp of the questions, and Part 2 [32] the second two questions. prototype; students are focused on learning the diagnoses; This text, Part 3, covers the fifth and six questions. The and researchers are required to be careful that their final Part 4 of the article will contain the general research subjects meet the criteria. conclusion. It is difficult to avoid the conclusion that the diagnostic criteria are mainly useful for researchers, who are obli- Question #5: How compatible are all the purposes of gated to insure a uniform research population. In this re- DSM? gard, it is an ironic side effect of the diagnostic criteria Is there a conflict over utility in the DSMs? The that they may impede research by confining research authors of DSM-III, DSM-IV, and DSM-5 intend the efforts to criteria-determined questions [35]. manuals to be useful for both clinicians and research- The introduction of dimensional measures into DSM-5 ers. Is there a conflict between what is useful for clini- adds a further wrinkle to this discussion. Regier and col- cians and what is useful for researchers? Which group leagues have written: “The single most important precon- is served better by DSM-III and DSM-IV, and by the dition for moving forward to improve the clinical and prospective changes in DSM-5? scientific utility of DSM-5 will be the incorporation of simple dimensional measures for assessing syndromes Introduction within broad diagnostic categories and supraordinate Any discussion of the utility question in DSM-5 should dimensions that cross current diagnostic boundaries.